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Annals of General Psychiatry
Open Access
Case report
ECT associated musical hallucinations in an elderly patient: a case
report
Raguraman Janakiraman*
1
, Keith Wildgoose
2
and Kalyan Seelam
1
Address:
1
Department of Psychiatry, Sheffield Care Trust, S5 7JT, UK and
2
Department of Psychiatry, Doncaster Royal Infirmary, DN2 5LT, UK
Email: Raguraman Janakiraman* - ; Keith Wildgoose - ;
Kalyan Seelam -
* Corresponding author
Abstract
Electro Convulsive Therapy (ECT) is a medical treatment for severe mental illness in which small,
carefully controlled electricity is applied to the brain. This electric stimulation is done in
conjunction with anesthesia and muscle relaxant medications to produce a mild generalized seizure.
This is used to treat a variety of psychiatric disorders. This is most effective in the treatment of
severe depression providing a rapid relief. We report and discuss an unusual presentation of a
ninety three year old lady with a diagnosis of Major Depressive Disorder, Recurrent, Severe with
Psychotic features (296.34) who experienced musical hallucinations whilst she was treated on ECT.
Clinically there was an inverse relationship between the biological symptoms of depression and

musical hallucination during the ECT management. Though similar reports have never been
reported earlier, we noticed a good association between the initiation of ECT and musical
hallucination in our patient. The patient stopped experiencing musical hallucinations and improved
of her biological symptoms of depression completely after the full course of ECT.
Background
Hallucinations may occur in any sensory modalities.
Formed musical hallucinations (i.e. Perception of either
vocal or instrumental melodies) reported in English liter-
ature to date have typically been associated with marked
hearing loss, advanced age, female sex (71%), lack of
response to treatment and associated psychopathology [1]
but has been concluded that hearing loss is neither a nec-
essary nor sufficient condition for the occurrence of musi-
cal hallucinations [1]. Tumor like Astrocytoma, Temporal
lobe epilepsy, raised intra cranial tension, drug induced
(tricyclics, Propronolol etc ;), meningitis and psychotic ill-
ness were shown to cause palinacousis and musical hallu-
cinations [2,3].
Musical hallucinations are pseudo hallucinations that
originate in memory representations and they may
undergo a transition to true hallucination. In musical hal-
lucination spatial projection is less definite. Sometimes
they are perceived like the tinnitus in patient's own head.
The quality is usually very intense and distinct often very
loud. They vary from elementary sounds to instrumental
music, vocal music, bird songs, bells, pieces of melodies
or sentences, religious music etc:- We report an unusual
presentation of an elderly lady who had experienced
musical hallucinations whilst being treated with Electro
Convulsive Therapy. Though this has never been reported

earlier, there seemed to have a good association between
the initiation of Electro convulsive therapy and musical
hallucination in our patient.
Published: 04 August 2006
Annals of General Psychiatry 2006, 5:10 doi:10.1186/1744-859X-5-10
Received: 10 January 2006
Accepted: 04 August 2006
This article is available from: />© 2006 Raguraman et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( />),
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Annals of General Psychiatry 2006, 5:10 />Page 2 of 3
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Case presentation
We report a case of 93 year old British lady, moderately
built, living in a residential home. She was admitted for a
few times in the past with a diagnosis of Major Depressive
episode, Severe with Psychotic symptoms. She had been
treated and stabilized with Mirtazapine 30 mg per day.
She never smoked or consumed alcohol. She had no past
history of chronic obstructive pulmonary disease.
Recently, she was admitted to Functional Ward with a
diagnosis of Major Depressive Disorder, Recurrent, Severe
with Psychotic features (296.34). She presented to us with
poor sleep, anergia, easy fatigability, poor concentration
and low mood. She was noted to have psychomotor retar-
dation with tear laden eyes and Veraguth's folds. She
firmly believed that dead people were around her and try-
ing to harm her. She also admitted hearing voices of dead
people telling her to die. She appeared distressed and
refused to accept food, drink and medications. She was

apparently stable in her mood until a month prior to the
current admission. She contracted lower respiratory tract
infection a month ago, for which she was successfully
treated with antibiotics. Despite this, her general condi-
tion deteriorated and she refused her medications, food
and drink.
Her general physical condition deteriorated further due to
poor hydration and self neglect. On admission, her neu-
rological examination was unremarkable. Her CT Brain
showed age related generalized atrophic changes. There
was no evidence of space occupying lesion, focal areas of
hemorrhage or infarction in the brain. Since there was no
history of seizures, focal neurological deficits and CT
Brain scan showing age related changes, EEG was not per-
formed.
It was felt in Multidisciplinary team that she would
improve with a short term course of eight ECTs. As she was
unable to consent, second opinion was sought and she
was posted for bipolar ECT twice a week for four weeks.
Pre-ECT investigations, ECG, Chest X Ray, Blood sugar
were normal. The ECT was carried out in conjunction with
anesthesia and muscle relaxant medications to produce a
mild generalized seizure. Though urea and creatinine lev-
els were deranged initially, they got stabilized once the
hydration had improved.
After the first two ECTs, she started accepting her food,
drink and medications. Her general condition and hydra-
tion improved. She was cheerful and humorous. She
started maintaining a good rapport, with appropriate con-
versation. She was more optimistic about her future.

Couple of days after the second ECT, she complained of
hearing musical notes and songs during most of the times
in a day. She heard "Rose in a garden of weeds" which she
pointed out to be her favorite song during her childhood.
This musical hallucination persisted up to few days after
the last ECT. Though she experienced the musical halluci-
nations, they were not distressing to her. The patient nei-
ther experienced the hallucinations nor could recall the
song after the completion of the course of ECT. Her
depressive symptoms improved. She was stabilized on
Mirtazapine 30 mg per day again and discharged to the
residential home.
Musical hallucinations are not uncommon in many psy-
chiatric illnesses, dementias, organic causes, drug induced
problems etc; none has been reported to be associated
with ECT therapy. Though Wengel SP et al reports that
ECT is very effective in treating depression and musical
hallucinations [1], in our patient; ECT which was started
for severe depression has shown a temporal association
with the origin of musical hallucination during recovery
from depression. Hearing loss is neither a necessary nor
sufficient condition for the occurrence of musical halluci-
nations.
Conclusion
Palinacousis (Auditory perseveration) is a rarely reported
symptom of temporal lobe dysfunction. Patterson MC et
al, reports palinacousis in a patient suffering from grade
IV astrocytoma over left temporal region with generalized
seizure. The patient's palinacousis improved with antiep-
ileptic therapy [2]. Neuroanatomically patients with

musical hallucination in comparison with controls had
increased regional cerebral blood flow in left temporal
region and left angular gyrus [4]. Takeshi Terao et al
reports similarities between palinacousis and musical hal-
lucinations, though there are some differences in their
contents. Both the symptoms are often associated with
seizure activity and there have been several case reports
where anticonvulsants were successfully used to treat both
symptoms [5]. Another case report by Roberts DL et al has
shown episodic musical hallucinations associated with
seizures that led to the discovery of 2 small intracranial
aneurysms [6]. These findings indicate the possibility that
there might be a common pathway generating musical
hallucinations and palinacousis to explain the cause and
effect relationship with seizure activity.
More over in the case reported by us, patient developed
the musical hallucination immediately after second ECT
which persisted during the complete course and disap-
peared few days after the last ECT. She neither experienced
the hallucination nor could remember the song she heard
which could possibly be because of ECT induced memory
loss. The pathophysiology of musical hallucination is dis-
cussed considering the theories of deafferentiation includ-
ing the concept of auditory Charles-Bonnet Syndrome of
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Annals of General Psychiatry 2006, 5:10 />Page 3 of 3
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sensory auditory deprivation, of parasitic memory, spon-
taneous activity of cognitive network module. So, musical
hallucinations are a phenomenon with heterogeneous
clinical and pathophysiological backgrounds of other
mental disorders [7]. The pathogenetic role of the musical
hallucination is mostly interpreted in terms of perceptual
release theory [8]. The continuous input of sensory stim-
uli is thought to inhibit the memory traces stored in neu-
ronal circuits, always ready for reactivation. If this input is
reduced below threshold level with sufficient cortical
arousal, this results in disinhibition, release and con-
scious perception of engrams.
In a phenomenological study of thirty consecutive refer-
rals of old people with musical hallucination concentrat-
ing on the names of the melodies heard, Hymns and
Christmas carols was the most common experience with
"Abide with me" particularly being the most frequent [9].
In this report, interestingly musical hallucinations seem to
have good association with the course of ECT which is not
reported so far. Further neuroanatomical study in future
may unravel the complex issues behind this association.
This study involves only a single individual and therefore

may not be representative of the general group. In future,
this needs further exploration by systematically analyzing
a large sample with control group.
Competing interests
The author(s) declare that they have no competing inter-
ests.
Authors' contributions
RJ made substantial contributions to conception and
design of the case report, drafted the manuscript and
revised it critically for important intellectual content. KW
initiated to write up the manuscript and had given the
final approval of the version to be published. KS was
involved in drafting and revising the case report along
with first author.
Acknowledgements
The authors acknowledge the expert comments given by Dr. KN Foun-
toulakis and Dr Timothea Toulopoulou.
References
1. Wengel SP, Burke WJ, Holemon D: Musical Hallucinations. The
sounds of silence? J Am Geriatr Soc 1989, 37(2):163-6.
2. Patterson MC, Tomlinson FH, Stuart GG: Palinacousis: a case
report. Neurosurgery :1088-90. 1988, June 22
3. Gadecki W, Ramsz-Walecka I, Tomczyszyn E: Case of musical hal-
lucinosis. Psychiatr Pol 2002, 36(3):449-55.
4. Mori T, Ikeda M, et al.: Regional cerebral bloodflow change in a
case of Alzheimer's disease with musicalhallucinations. Dept.
Of Neuropsychiatry, Ehime University School of Medicine, Toon city,
Ehime; 2005 in press.
5. Terao T, Matsunaga G: Musical hallucinations and palinacousis.
Psychopathology 1999, 32(2):57-59.

6. Roberts DL, Tatini U, Zimmerman RS, Bortz JJ, Sirven JI: Musical hal-
lucinations associated with seizures originatingfrom an
intracranial aneurysm. Mayo Clin Proc 2001, 76(4):423-6.
7. Evers S, Ellger T: The clinical spectrum of musical hallucina-
tions. J neurol Sci 227(1):55-65. 2004 Dec 15
8. West LJ: A general theory of hallucinations and dreams. In
Hallucinations Edited by: West LJ. New York: Grune & Stratton;
1962:275-291.
9. Warner N, Aziz V: Hymns and Arias: Musical hallucinations in
older people in Wales. Int J Geriatr psychiatry 2005, 20(7):658-60.